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\begin{document}

\title{Transcatheter repair of a left ventricular outflow tract pseudoaneurysm
following composite aortic root replacement using an Amplatzer Septal
Occluder}



\author[1]{Cynthia Kiang}%
\author[1]{Praveen Sridhar}%
\author[1]{Karl Karlson}%
\author[1]{Robert Eberhardt}%
\author[1]{Niloo Edwards}%
\author[1]{Meaghan Doucette}%
\author[1]{Nikola Dobrilovic}%
\affil[1]{Boston Medical Center}%


\vspace{-1em}



  
  \date{May 05, 2024}


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\selectlanguage{english}
\begin{abstract}
The emergence of endovascular techniques has enabled minimally invasive
options for repair and salvage of postoperative sequelae from complex
aortic operations. There have been few reports of percutaneous
transcatheter repair of aortic pseudoaneurysms after composite aortic
root replacement with reports of only two patients with follow-up longer
than two years. We report a case of a 35 year man who developed an
aortic root pseudoaneurysm following a composite aortic root replacement
and was successfully managed by transcatheter repair using an Amplatzer
Septal Occluder without evidence of recurrence at two year follow-up.%
\end{abstract}%



\sloppy




\textbf{Case Report}

The patient is a 35 year-old man with Type II Diabetes Mellitus,
hypertension, hyperlipidemia, and morbid obesity (BMI 37) who presented
in 2009 with a symptomatic 7.7 cm ascending aortic aneurysm. He had no
prior history of cardiac disease, no family history of connective tissue
disorders and no history of aortopathy. At his initial presentation, the
patient presented with severe palpitations and was found to have severe
aortic insufficiency (AI) with an annular diameter of 33mm and preserved
left ventricular (LV) function. He underwent a ``Modified Bentall''
composite aortic root replacement via median sternotomy and
cardiopulmonary bypass{[}1{]}. Arterial cannulation was achieved via the
femoral artery and right atrium, retrograde cardioplegia was
administered via the coronary sinus and the LV was vented via the right
superior pulmonary vein. The aorta was cross-clamped proximal to the
innominate artery. A \#31 composite St. Jude mechanical valve conduit
was used. The proximal anastomosis was completed using interrupted
sutures while the distal anastomosis was performed using a running
suture repair with pledgeted reinforcement. Coronary buttons were
fashioned and anastomosed to the graft conduit. An intraoperative
transthoracic echocardiogram (TEE) showed no paravalvular leak. The
patient had an unremarkable postoperative course and was progressing
well at follow-up.

Ten months post-procedure the patient presented to the emergency
department with complaints of chest pain. Imaging with a computed
tomography with arterial phase contrast (CTA) revealed contrast
extravasation at the level of the aortic annulus suggesting an
anastomotic pseudoaneurysm; however, transthoracic echocardiography
(TTE) at this time did not show evidence of flow into this space (Figure
1). His symptoms resolved and no intervention was undertaken at this
time. The patient was followed with serial CTAs.

Eight years following his repair, our patient was found to have
pseudoaneurysm enlargement on surveillance CTA from his prior imaging,
and again endorsed symptoms of intermittent chest pain (Figure 2). He
underwent TEE which the previously identified pseudoaneurysm at the
level of the proximal anastomosis in the interatrial septum. Left heart
catheterization was subsequently performed and confirmed the
extravasation of contrast proximal to the mechanical valve and into the
pseudoaneurysm space (Figure 3).

The patient was discussed in multidisciplinary conference including
cardiology, interventional cardiology, cardiac surgery, and
anesthesiology. Re-operation for pseudoaneurysm repair was weighed
against percutaneous endovascular repair and discussed with the patient
and the decision was made to pursue percutaneous closure of the defect.

The procedure was performed under general anesthesia with intraoperative
TEE guidance. Two transseptal punctures were performed for angiography
and for device deployment via an 8.5-Fr sheath in the right femoral
vein. The pseudoaneurysm space was accessed using a 6-Fr glide catheter
and angled glidewire. The defect size was measured approximately 10mm. A
14mm Amplatzer\textsuperscript{TM} Vascular Plug II (Abbott
Laboratories; Chicago, IL) was placed, however persistent leak was
noted. An 8mm Amplatzer\textsuperscript{TM} Septal Occluder (Abbott
Laboratories; Chicago, IL) device was then deployed. This resulted in a
stable position of the plug and moderately improved the leak by color
flow and angiography. TEE confirmed residual but significantly improved
shunt flow. The procedure was concluded and the patient was admitted
post-procedurally for observation. A TEE was repeated on post procedure
day one and showed the vascular plug near in appropriate position with
residual trace AI observed. The patient recovered uneventfully and
underwent repeat TTE at 3 month follow-up.

TTE at follow-up revealed no obvious AI in the area of the device and
the previous pseudoaneurysm was no longer evident. The patient also
underwent a follow-up CTA at that time and the previously seen
extraluminal contrast collection was no longer present. Specifically,
the previously seen pseudoaneurysm abutting the aortic root had
decreased in size and thrombosed (Figure 4). The patient has resumed
regular activity and remains free of recurrence two years following his
intervention.

\textbf{Discussion}

Endovascular technologies are increasingly available to clinicians as
options for minimally invasive approaches to complex pathologies
{[}2--6{]}. While an anastomotic pseudoaneurysm following aortic root
replacement is a rare sequela, it poses a challenge given the added
morbidity and potential mortality of a reoperative sternotomy {[}7,8{]}.
The Amplatzer\textsuperscript{TM} Septal Occluder has been previously
used in a limited fashion for percutaneous closure of aortic
pseudoaneurysms in 13 cases, of whom only two had prior aortic root
replacements {[}5,6{]}. While there is some evidence that transcatheter
approaches may not be effective, we present a clinical scenario of a
postoperative pseudoaneurysm arising from the left ventricular outflow
tract (LVOT) of a patient who had previously undergone a composite root
replacement {[}3{]}. Given the morbidity and potential mortality of an
open repair, the patient underwent a successful percutaneous
transcatheter repair with radiographic resolution seen two years
following the intervention. This case adds to recent literature
suggesting that alternative techniques to open repair may be safe and
durable for the salvage of composite root replacements with
pseudoaneurysmal complications. While the transcatheter repair has been
limited to patients who are truly not operative candidates, it can be a
useful tool to employ depending upon the resources available to the
clinician and preferences of the patient.



\textbf{Figure Legend}

\textbf{Figure 1 --} Arterial phase Computed Tomography (CTA) in the
axial view at initial diagnosis of pseudoaneurysm. (A) Right main
coronary ostium, (B) Left main coronary ostium, (C) Pseudoaneurysm with
contrast extravasation (arrow), (D) Pseudoaneurysm in largest dimension
arising from the left ventricular outflow tract (LVOT) (arrow).

\textbf{Figure 2 --} CTA, axial images, demonstrating interval growth of
pseudoaneurysm. (A) Right main coronary ostium, (B) Left main coronary
ostium, (C) Pseudoaneurysm with contrast extravasation (arrow), (D)
Pseudoaneurysm in largest dimension arising from the left ventricular
outflow tract LVOT (arrow).

\textbf{Figure 3 --} Left heart catheterization via transseptal puncture
revealing contrast extravasation from the LVOT proximal to the
replacement aortic valve.

\textbf{Figure 4 --} CTA, axial images, demonstrating resolution of
previously documented pseudoaneurysm. (A) Right main coronary ostium,
(B) Left main coronary ostium, (C) Thrombosed pseudoaneurysm sac, (D)
Thrombosed pseudoaneurysm with no contrast extravasation from the LVOT.

\textbf{References}

{[}1{]} Bentall H, De Bono A. A technique for complete replacement of
the ascending aorta. Thorax 1968;23:338--9. doi:10.1136/thx.23.4.338.

{[}2{]} Hao F, Genshaft S, Kee ST, Canan T, Yang EH, Moriarty JM.
Percutaneous Transthoracic Treatment of Ascending Aortic and Root
Pseudoaneurysms: Procedural Aspects and Guidance with the Use of
Multimodality Imaging. J Vasc Interv Radiol 2018;29:628--31.
doi:10.1016/j.jvir.2018.01.767.

{[}3{]} Hibino M, Katada Y, Shibayama K, Obunai K, Watanabe H, Kawano Y,
et al. Recurrent aortic root pseudoaneurysm after transcatheter
occlusion---A word of caution. J Card Surg 2018;33:190--3.
doi:10.1111/jocs.13568.

{[}4{]} Yin WH, Wei J, Tsai SK, Hsiung MC, Lee YT, Yu HP, et al.
Transcatheter intervention for complex ascending aortic pseudoaneurysm
after cardiac surgery. Circ J 2014;78:2215--8.
doi:10.1253/circj.CJ-14-0154.

{[}5{]} Kanani RS, Neilan TG, Palacios IF, Garasic JM. Novel use of the
Amplatzer\selectlanguage{ngerman}® septal occluder device in the percutaneous closure of
ascending aortic pseudoaneurysms: A case series. Catheter Cardiovasc
Interv 2007;69:146--53. doi:10.1002/ccd.20794.

{[}6{]} Steinberg ZL, Don CW, Sun JCJ, Gill EA, Goldberg SL.
Percutaneous Repair of Aortic Pseudoaneurysms: A Case Series. J Invasive
Cardiol 2016;28:E6--10.

{[}7{]} Mulder EJ, Van Bockel JH, Maas J, Van Den Akker PJ, Hermans J.
Morbidity and mortality of reconstructive surgery of noninfected false
aneurysms detected long after aortic prosthetic reconstruction. Arch
Surg 1998;133:45--9. doi:10.1001/archsurg.133.1.45.

{[}8{]} Maroto LC, Carnero M, Cobiella J, García M, Vilacosta I,
Reguillo F, et al. Reoperation for composite valve graft failure:
Operative results and midterm survival. J Card Surg 2018;33:330--6.
doi:10.1111/jocs.13710.\selectlanguage{english}
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